Provider Demographics
NPI:1245730787
Name:JOHNSON, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17688 71ST LN N
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-5501
Mailing Address - Country:US
Mailing Address - Phone:954-696-4135
Mailing Address - Fax:954-272-7968
Practice Address - Street 1:17688 71ST LN N
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-5501
Practice Address - Country:US
Practice Address - Phone:954-696-4135
Practice Address - Fax:954-272-7968
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician